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There is no more mystery to why so many of us are fat in the modern world - and yes, stated bluntly, so, so many of us are- than there is to why humans drown if under water too long. In both cases, placing ourselves where we are ill-adapted to be leads ineluctably to mayhem.
We might argue, in both cases, that the problem is genetic. Humans caught under water for too long drown. This is genetic, if we invoke the want of genes coding for human gills during our embryological origami. But this is a bit absurd in its own right, and invites only further absurdities. Death by gunshot wound to the chest is genetic- because we lack genes to make us bullet proof. And so on, into a labyrinth of the ludicrous.
Accordingly, I would contend that pandemic obesity is no more genetic than the propensity to drown. Humans are not adapted to drift daily up to our eyeballs in willfully engineered, hyperpalatable, energy-dense Frankenfoods and labor-displacing technologies. Calling the consequences “genetic” is a bridge too far for me.
There is another argument against a “genetic cause.” The “effect” of interest has shifted staggeringly over the past century, during which time human genes have shifted trivially if at all. If we contend that “A” causes “B,” and “B” changes monumentally, we must look to a corresponding change in “A.” Absent that, something else is responsible for the change in “B.”
The final word on that topic might issue from migration studies. Such studies show that humans become prone to obesity and chronic disease when living in the places where these prevail, even if not prone to the same in their places of origin. That humans take their genes with them when they relocate should not require attestation.
We can also know, and for closely related reasons, that pandemic obesity is not for want of self-control, will-power, or personal responsibility. We have neither cause to believe, nor evidence to suggest, that the native human endowment of these attributes has suddenly plummeted in tandem with burgeoning obesity. We certainly have no cause to think the current crop of 7, 8, or 9-year-olds is less personally responsible than every prior crop, yet they are stunningly more prone to obesity and its consequences. As with genes, we may expect that the exercise of personal responsibility travels with its human hosts- whereas the exercise of exercise, and eating well, do not.
Quite simply, neither genes, nor individual victims, are “to blame” for pandemic obesity. So what is?
Just about everything else. Seriously- look around. The causes of pandemic obesity are the proverbial elephant in the room, and the only way not to recognize them is to miss the whole pachyderm for its parts- a famous fallibility, alas.
We have been told, brilliantly, and more than once, that the modern food supply is willfully engineered to be addictive in the service of maximal eating, purchasing, and at the supply side- profits. If any among you doubt that food can be addictive- despite the evidence that it is- permit me to say you may not understand why addiction is possible. The reward mechanisms responsible for every aspect of addiction were chiseled into the human nervous system, in the service of survival, by evolutionary biology. The rewards- intense pleasure and gratification- were “built” for actions conducive to survival today (e.g., eating) and tomorrow (e.g., mating). What, after all, is more universally, viscerally, and immediately rewarding than a really great meal, or a really great…well, you know.
That food and sex are essentially “addictive” should be a given; questions should be reserved for why anything else is. The answer is that some drugs are able to hijack the nervous system pathways laid down for food and sex, because they resemble the body’s intrinsic chemical messengers of reward.
We can look around and see that food- something essential to our survival- is actively and aggressively marketed to us anyway, not because we need encouragement to eat- but because such encouragement can goad us into too much of all the wrong things.
Willfully manipulated, and manipulative, hyperpalatable, energy-dense food no longer requires foraging, hunting, or any effort at all. It is ubiquitous, and constant. In contrast, the physical exertions survival once required are now obsolete, and inconvenient. Technology displaces ever more native movement from the typical Homo sapien day with each innovation cycle.
Political regulation of any of this is precluded by those quick to denounce a “nanny state.” The House of Medicine, rather than calling out the cultural misappropriation of food and its systematic replacement with ultraprocessed junk, has instead declared obesity a “disease,” inviting innovations in pharmacotherapy. Thus, Big Pharma can profit by treating what Big Food profits by causing, and everyone wins- except all of us, the growing legions of the sick, fat, and fed up.
Finally, to invoke a simile that dates from the earliest days of my career- we are like polar bears in the Sahara, beautifully adapted to one environment, consigned to live in its (non-polar) opposite. We are as indelibly adapted to real food, not too much, mostly plants and a bounty of daily activity as are polar bears to cold and snow. We humans have abundant metabolic protections against starvation, and effectively none against caloric excess, the lure of the couch, and attendant obesity- never having needed those before. We can’t thrive here, because we don’t belong here, in this place of irresistible, ingestible junk we have blithely contrived.
The storm fomenting global obesity is so nearly perfect that the only legitimate mystery would be the absent effect of so florid a cause. Given prevailing conditions, pandemic obesity is a fait accompli. A majority of adults and an alarming percentage of children in every nation long exposed to junk where food ought to be and technology where movement ought to be- are overweight or obese. Not just some, and not just many; a majority. Finding mystery in this is like attempting to explain how Titanic passengers could have drowned -for reasons OTHER THAN the iceberg, sunk ship, and frigid ocean. Sure, if we exclude the overwhelmingly obvious…we are left with mystery.
Writing on the topic of obesity this soon after Thanksgiving, and with the “holiday season” stretching before us may come across like a squeeze of lemon juice into your paper cut. Forgive me if so; my excuse for the timing is that it was provoked.
That provocation was a generally excellent column on obesity by Julia Belluz in the New York Times. Julia- a health journalist I greatly admire, and whose work was recognized with an inaugural REAHL (Recognizing Excellence in Advancing Health Literacy) Award from the True Health Initiative, a non-profit I founded- was principally making the point that despite many differences about details, obesity experts from around the globe and many disciplines agree that the problem is not gluttony or personal-responsibility-deficiency-syndrome. The column, based on attendance at a scientific conference in the UK exploring explanations for pandemic obesity was, above all, a case against blaming the victims. I concur, most heartily.
Beyond that, the piece further acknowledged some consensus related to environmental influences and food policy. But still, the headline – “Scientists Don’t Agree on What Causes Obesity, but They Know What Doesn’t” – emphasized discord rather than accord. Having experienced this process myself, I suspect the headline was not Julia’s, but rather the choice of an editor adept at attracting eyeballs. Of note, the same piece by Julia has appeared elsewhere with a very different header: “Obesity: A rare consensus among scientists on what doesn’t explain why we’re fatter.”
So, really, it was the New York Times header that provoked me, because an emphasis on discord is dangerous. This is just the sort of thing the infamous Merchants of Doubt have long exploited to extend their hegemony, elevate their profits, and stall the advent of any effective remedy. Scientific discord about what “causes” pandemic obesity is all the cover its intentional, lucrative propagation requires.
What, then, the way forward?
First, I believe we actually can, and should, treat rampant obesity as a form of drowning- an argument I have made at every opportunity. We do not look at drowning and debate causes in the individual (e.g., genes, ethnicity, attitude, aptitude, character, responsibility, etc.) nor in the water (e.g., salinity, osmolarity, pH, density, etc.). Rather, we accept the obvious: humans do poorly when spending too long in a place they are ill-adapted to be.
This analogy matters, because we mobilize diverse resources to reduce the risk of drowning to the irreducible minimum, and reserve treatment for the regrettable cases that occur nonetheless. Obesity might be addressed in just the same way, with anti-obesity analogues to swimming lessons, lifeguards, parental vigilance, warning signs, and fences around pools- coming readily to mind. None of this will occur so long as those favoring fiddling while public health burns can invoke “mysterious causes” to oppose any targeted action.
Second, I believe the discord observed in the meeting described by Ms. Belluz is in some sense an optical illusion. We were able to evince that same problem with regard to “healthful eating” some years ago at a novel and important conference. Rather than asking for a diverse group of experts to state their mutually exclusive case for “best diet,” we asked them to highlight essential elements of any high-quality diet for the health of people and planet. The answers to that were overwhelmingly confluent, and were published on-line accordingly.
The same might be done for obesity, and Ms. Belluz’ reflections on the conference she attended suggest it should be. A “common ground” obesity conference would not explore competing theories of contributing causes, but would instead ask: “what are the major, fixable contributors to pandemic obesity you deem most important?” I would be shocked not to see a whole lot of overlap in those answers, and that overlap could and should be a cue to action.
The headline there- “massive agreement among experts worldwide about causes, cures for pandemic obesity”- would deny cover to the obesity merchants of doubt, and would make further delay by relevant authorities something of an embarrassment. From the House of Medicine to Madison Avenue, from elections to elementary schools- a gauntlet would be thrown down.
Given the staggering, global toll of obesity on public health, that day cannot come soon enough.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.
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